Sensing Light by Mark A. Jacobson

the two weeks before that are on me.”
    â€œI don’t think so. The bar is totally different for a clinic doc. You’d need ESP to pick out the one in ten thousand patients with a cough and weight loss who’s going to turn out to be a zebra and crash like this.”
    â€œMaybe.”
    She looked at the ICU entrance and said, “Uh-oh.”
    Kevin turned around to see Herb marching toward them. He jumped up to intercept Herb at the nurse’s station.
    â€œWhat’s his arterial oxygen?” Herb demanded.
    Herb had never spoken to him so curtly. It unnerved Kevin. He responded immediately, forthrightly, as he had when a schoolboy, caught red-handed committing a venial sin by one of the nuns.
    â€œIt’s been in the forties since midnight,” Kevin confessed, half-expecting Herb would order him to say thirty Hail Mary’s.
    Instead, Herb’s shoulders sagged. Head bent down, he whispered an expletive. When Herb lifted his gaze, Kevin saw no anger, only resignation.
    Gwen joined them. Herb mechanically acknowledged her presence.
    â€œThe silver stain is positive for Pneumocystis,” said Herb.
    â€œThat’s what the path showed?” said Kevin in disbelief. “Isn’t Pneumocystis a parasite?”
    â€œThat’s right.”
    â€œI thought it just occurred in immunocompromised people?”
    â€œExactly.”
    Gwen, who knew even less about Pneumocystis than Kevin, asked if the infection could be treated.
    â€œWe can give him trimethoprim-sulfamethoxazole. Though at this point, it’s not likely to make a difference.”
    Holding up the blood gas printout as evidence, Herb added, “He’s had so much lung destruction, the odds of his ever getting off the ventilator are nil. And with these numbers, he’s had enough hypoxic brain damage that if he does survive, it’ll be in a vegetative state.”
    Kevin and Gwen reddened simultaneously.
    Gwen stared at Kevin. How could he possibly think it was his fault now, she asked herself.
    â€œGuys,” Herb said gently, “treating Pneumocystis pneumonia is just winning a battle. You still lose the war if the underlying immune deficiency can’t be reversed.”
    Neither Kevin nor Gwen was mollified.
    Herb looked away and said, “You’re right. There’s no good excuse for losing a patient to a treatable infection, especially when it’s one you’ve seen before.”
    Gwen’s remorse was supplanted by amazement. This senior specialist had just taken on the entire responsibility for Larry Winton’s imminent death, while two other candidates stood by, ready and willing to accept the blame.
    â€œYou’re sure it’s Pneumocystis?” asked Kevin, his eyes deflected downward.
    â€œThink about it. The x-ray appearance, the time course of his illness, the negative micro studies, no history of an autoimmune condition to account for his lung disease. At NIH, I saw kids with leukemia who developed Pneumocystis pneumonia on chemotherapy. Clinical course and findings exactly like this case. Which is why I asked the lab to do a silver stain on the bronch washing. They thought I was nuts, but the slide had textbook cysts. Lots of them. Of course, that raises the question of why the hell this youngman’s immune system wasn’t working. He wasn’t getting chemotherapy. He wasn’t getting steroids. He didn’t have a history of serious infections like someone with a congenital immune deficiency would have. It doesn’t make sense.”
    Perplexed, Gwen nodded in agreement. Kevin went off to retrieve the chart and began writing a medication order for trimethoprim-sulfamethoxazole. As he asked Herb about the dose, she returned to Larry’s room. She watched the monitor tracking his heart’s electrical activity. A white dot moved across the screen, forming a series of identical waves. Suddenly, the pattern disintegrated into chaotic